We're going to show our last device and last technique that we're going to show today, which is one of our scope and lumen stabilization devices. We'll be showing the Lumendi Dilumen device, which is this thing. I'll let you hold that part, and I will pour it over here. So this is a scope and lumen stabilization device. It is, as you can tell here, it looks like an overtube, and that's because it is. And it looks very similar to balloon overtubes, and that's because this is basically a double lumen overtube. So it has a couple of functions. The first is on this part of the device, the handle. I'll start by, where does the scope go? Well, the scope goes in this giant purple tunnel. And this part has a nice dial here, righty, righty tighty. So right that way, left that way. And what it does is it tightens the cap around the scope when it's in there. So what you can do is you can position your scope through the lumen of the device, and then you can tighten it around it to help hold the overtube in the same location. Second part, if you'll hold that, is to show this little handle here, same thing. It has a turn right to tighten, turn left to loosen. So it helps you lock or unlock to stabilize this part. And what we'll show here is if you show the handle and show this part. So Shifu, if you go ahead and push this down, so push that purple thing down, it extends the two balloons away from each other. So what it does is it pushes the forward balloon up, and it keeps the back balloon in the same location. This is what provides that double balloon scope stabilization part that allows you to create a part of the colonic lumen that is stable and flat to then do your endoscopic resection work. The company has also put a little suture here on the forward balloon to help you use that preset suture in case you wanted to use it for traction on your ESD or for other things. You can now have a suture to use as an anchor point. So I'll have you go ahead and retract that balloon back and then lock it in position. So I'll have you turn it righty, right, until it's tight. Perfect. The last part of the device, if I trade your hands, I'll have you hold that part too and show that to everyone, is the control handle for the balloons. And so this is basically a bulb type of thing that you can squeeze. I don't know what the name of it is. And then this has our different four control points. So directions that are pointing closer to the balloon or to the handle represent your back balloon. The two directions pointing towards the front of the device represent your forward balloons. You can turn this control knob to any of these four directions. The negative ones on both sides represent deflation. The positive ones on both sides represent inflation. So if I wanted to go ahead and inflate the back balloon, I turn it to this direction, positive on the back balloon. And I can go ahead and start squeezing. You'll see right now the indicator symbol for the back balloon is this red-yellow, means it's deflated. If I start squeezing, you'll see two things. You'll start seeing the balloon inflate. And this is specifically the back balloon is inflating as I squeeze. And you'll see the indicator light going green. And when it's green, you know the back balloon is inflated. If I want to inflate the forward balloon, I turn the dial forward to the positive side. And I start squeezing. And I will be inflating the forward balloon. If I want to deflate the balloon, then I switch it to negative. Well, let's inflate all the way so you can see it turn green. So now it's green. It's fully inflated. If I want to deflate, I turn it here. It's on the negative side. I start squeezing again. And it deflates the same balloon. And I keep squeezing until it's nice and close to red. And then the same thing, I want to deflate the back balloon. I start deflating and squeezing more until my hand is tired and the balloon is fully deflated. So I know it's kind of complicated. It's a lot of steps here. But this is really kind of a single system that allows you to have two balloons to stabilize the lumen, stabilize your scope, and create a flat workplace for ESD or endoscopic resection in the colon. So the last couple of minutes, we'll go ahead and let's go ahead and insert our scope through this device. The key part of this tube, just like any other over tube that we use in GI endoscopy, is to get the inside of the tube wet. So before we actually started our demonstration today, we did insert just some regular water through the inside of the tube and ran that water back and forth, just like this, just to get the inside of the tube wet. Now that the tube is wet, we can go ahead and loosen our purple dial there. And we'll insert our scope through the device like so. We'll keep going. And generally for intubation, what's common is to have the turning section of your scope out of the device. And that's probably good enough. And once we have it on there, I will now turn the purple dial right or clockwise until it's snug around the scope. So now that I've tightened it, you can see if I pull on the scope here, it's not going to move. So I've fixed the scope and the over tube together at this amount. So now I'll pass it over. And we will go ahead and insert. So this is a nice, easy, relatively straight pig colon. So it's easy to work with. And it's easy to intubate. This is not the case for human beings. Sometimes it is challenging. So why don't you just come back. We'll just use a section back here if that's all right. OK, so once we've gotten to our lesion, one of the first steps if you're going to use this device is to stabilize the scope and stabilize your position by inflating the back balloon. So that's what I'm going to go ahead and do here. And I'm going to inflate the back balloon. And so I'm squeezing until my back balloon indicator is at green. And you can see it's green now. And so it's there. If you do want to show the colon model, you can see here on the colon model, our back balloon is right here. And it has been inflated and is now stabilizing the scope against that section of the colon. So now that I've done that, you have some options here. I'm going to loosen the endoscope on the over tube. So that'll allow Chifa to go ahead and move the endoscope forward or backwards. You'll have to move it from here. I'm sorry. So she can move it forward. She can move it back. But I think back is probably a little bit more important right now. So we can pull the scope out some. And you can see as we come back, we come back. We can see now that edge of that balloon. So one of the nice features of this device is to then to try to use the forward balloon to create yourself a straight workspace. So what I'm doing is now loosening the control of the forward balloon here. And what we're going to do is we're going to advance the forward balloon forward. So you can see I'm pushing it forward. And that's advancing this forward balloon through the colon. And the idea is to have the forward balloon now be on the other side of the lesion. Now that I've done that, I will go ahead and inflate the forward balloon. And I'm going to squeeze until this thing turns green. And I can also see visually the forward balloon expanding. So now I've got both balloons up. And if you go to the model here, you can see what we've done. We've taken what could have been a nice curved colon into a straight area of colon anchored by both balloons. And so now if I just hold this handle for you, and if now you are doing your resection, you can move the scope back all the way back to the back balloon right here. And imagine our lesion is sitting right here in the center. And it's now this whole section of the colon is nice and straight. It's nice and flat. You've created your own enclosed kind of ecosystem within the colon fixated by these two balloons. Air, liquid, not really going outside of this. And now you have a nice straight workspace with a suture on the front end in case you needed additional traction. And so then we could go ahead and do our regular ESD. So you could do this for ESD or EMR. And so let's go ahead and start and just see how the working goes. So I'll hand you this. And this is the one challenge of this device is that you're working through an overtube. And so as you can see, the challenge of holding the overtube and the scope. And I got some of these things. So we'll inject something. I may not have given you a needle long enough. Nope, I gave you a only one that fits on the stomach. Let's get another needle if you got one. Different needle? Colon needle. Colon needle, one with a colon length. All right, we're gonna get a needle that probably won't fit down there and those things. All right, so really the whole purpose here is you can see the value of this scope stabilization, lumen stabilization, lumen flattening. This is really the purpose of this device and to make then you've got this advantage for while you do ESD as opposed to when you do it without it, you have this more challenging colon anatomy to kind of deal with. And this device works with all like PCF and adult scopes? It does. The nice thing is that this is an adult scope that we have down here and so it does fit down any colonoscope. You can actually use a gastroscope down here if you want as well. Generally if you're, if it's something in the rectum you probably don't need this device. Rectum is probably easy to do. This is really meant for if you're having something kind of in the right colon or more challenging to kind of have a stable scope position. All right, let's try this needle. Looks a little longer. So, you'll see more and more, and of the scope and lumen stabilization devices coming out. You know some there are some others on the market and others coming out. They all have their pros and cons to them, needle out. They all have their pros and cons to them that you know about how you use them. And, you know, one of the challenges of this is obviously working through, you know, a big over to just get remember this is where you got to move your scope from area. And so it is different, working through compared to what we're used to in general endoscopy. Yeah, definitely ergonomic those challenges extremely challenging from an ergonomic standpoint, injecting, injecting, injecting, injecting, maybe pull back a little bit, pull back a little bit, I tried different site because we went through here because it's stressed. Try different site, site, needle back, needle back. Let's try a different side. We squirted our camera crew, that's all right, they're tough. Nope, getting too tight here. I'm wondering if it's again a location issue. This is, we have this all stretched out, so it makes it difficult. This very thin area. All right, let's try moving this, this. There we go. Try with that. Okay. Needle out, inject. Nope through again. We got this too stretched out. So let's do this. Let me Take this for a second Let's try injecting with the balloon down But I'll push your scoop Go ahead. All right. There we go. Okay, let's try this area Yeah Needle inject. No, we're through already This we just stretched it out the colon too much. All right back. That's all right. Sorry. Let's see. We'll get it. We'll get it All right, we're getting some injection going here, maybe leaking into the peritoneum a lot. It's okay. We lost this patient a long time ago. Okay. All right, let's, let's do that. And then let's start cutting here. Back. Thank you. No problem. I don't know if this is going to be long enough, but let's see if it is. We're going to go with the ESD knife. Yeah. This might be long enough. We'll see. No, it's not going to be. Let's try a different one. Okay. Let's see here. 1650. So lesion right now is between the, both the balloons and the colon is stretched in between. Yep, exactly. That's not long enough either. Let's just use a snare because we don't have a knife at the moment long enough to fit down there. Okay. All right. So let's just grab that guy. I'll hold the device if you in the tube. That way you can just open do that. Yeah, no problem. Probably should have done that a long time ago but I forgot. We can probably cold snare this but if you're not connected right now. I'm not but I can be. It's pretty thin so it goes to go. All right, so remember, get it, you move the scope from here up here at the area. Okay, so here you're sure you got it. Yes, I got it. Okay. I'm trying to get this there out on it. Probably not the best demonstration of. That's all right. That's okay. We'll go with it. Okay, this is better. Pushing my snare. of slipping off the snare right now. Sometimes it is easier as weird as it sounds to not use the balloons and have them down because the balloons remember they fixate both ends of the colon and the scope so all your natural movements of moving the scope in and out are not necessarily there and your colon has become stretched. So I'm going to take both balloons down and that may give you a little bit easier maneuverability. It'll help us not stretch out so much of the colon and then let me pull this part back for you. Just pull that back. There we go. Now maybe a little looser of a colon to manipulate with. So, let me do this, because your front balloon is making your life a little hard, so I'll pull your front balloon closer to you a little bit, so you got a little less front balloon to stretch out. So this is one of the things, it's a lot of like different scope maneuvers and different handling than we're all used to once you use both balloons to fixate the colon. Yeah, it's definitely challenging to do the 360 degree torque on this colon. Yeah, actually you will not be able to do as much torque or other things that you're normally used to, so it's a fully different kind of technique and things to get used to. Some limitations to it. For those who have done or seen the surgeons do their transrectal excisions using their rigid devices, that's where you'll see a lot of this stuff that they have to do, so you want to hand that? Thank you. No problem. Okay, let's see here. All right, I'm going to have you just hold that over to you, if you don't mind. Let's see what happens here, if I can remember how to, okay, let's see here, sorry, there we go. I'm going to get this thing there, okay, cool, I just need to have this, why don't you bring that handle on the other side, probably disconnect it and do that, there we go, cool, okay. You want to just hold this, if you can, right there, perfect, thank you, let's see what we can do. All right, so I got that up there, this is, I think, our lesion, see what happens, going to open all the way? Open all the way. All right, so closing, closing, closing, snug, there's something, all right, let's see what happens probably cause a perforation but it's okay, all right, cut, cut, cut, cut, through, I'm through, okay, and yes I did, there we go, beautiful, all right, nice little hole there, not intended to be full thickness but we did it anyway, so that's all right, and let's see here, let's just take, let's just keep cutting here and let's see what happens, okay, so open, all right, that would be fine, that would be fine, yeah, yeah, all right, so closing, closing, closing, closing, snug, all right, let's see what we got here, all right, let's see if we can make this perforation bigger, all right, cut, cut, cut, cut, cut, let's see what we got here, oh yeah, even bigger hole, all right, cool, all right, so you can see how to create a perforation in case that's what you're trying to do, one option and we got ourselves this resection, all right, and you can see maybe our, I don't know who we're looking at, camera crew over there, hey guys, nice to see you, all right, I think that's only fitting for us to say thank you to everyone who attended virtually, thank you to our whole crew here at the live streaming virtual hands-on room at the IT&T Center, thank you to Shefa for coming and helping us out, thank you for all of our course directors for putting on what I hope all of you enjoyed today and I hope all of you enjoy tomorrow as well, so sit back, relax, watch some football, grab a beer, I'll pass you over to Dr. Templeton who will take you home, thank you. Thank you, bye-bye. All right, thank you guys, what a great demonstration of so many different tools and devices today, so just a quick summary, you know, a nice review of both EMR lifting agents, FTRD and now a stabilizing device in the form of Lumendy, looking forward to seeing everybody tomorrow morning bright and early, hope everybody got something out of today and please feel free to keep the questions coming, it's been really good to engage with everybody, thanks so much, goodbye.

Lumendi Dilumen device

endoscopic resections

double-lumen overtube

colonoscopes

gastropscopes

scope stabilization